Pitsmoor Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Patients received effective care and treatment that met their needs and patients were supported to manage their health and wellbeing. We observed from the clinical searches we carried out that the service delivered evidence-based care though some recording of risk advice and monitoring processes required review. The quality and safety of people’s care and treatment was effectively monitored, to improve their outcomes through clinical audits. Childhood immunisation and cervical cytology uptake was below national averages. However, the practice had taken action to improve these areas. For example, they had attended local schools to speak to parents and had liaised with patients to identify the barriers to attending for their cancer screening which had resulted in improved uptake. Staff worked well together as a team and said they were supported when required and the practice worked well with external partners to deliver services to their patients.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people using the service was mostly positive about care and treatment although they reported difficulty accessing the practice by telephone and to an appointment.

Staff had access to interpreter services and would put an alert on a patient’s record to highlight any communication or impairment needs. Staff actively referred patients to social prescribing to support with their wellbeing and social issues.

The provider had some systems in place to identify people with previously undiagnosed conditions. However, we observed some processes required review. For example, we identified on our clinical searches 125 patients with potentially undiagnosed chronic kidney disease (CKD). All these patients’ records were reviewed by a GP immediately following our clinical searches and appropriate action taken. People’s care needs were routinely reviewed. People with long term conditions were invited for an annual health check. The provider looked after several care homes. All patients had a care plan in place and a dedicated GP who supported the home. Clinical staff used templates when conducting care reviews to support the consistent review of people’s wider health and wellbeing. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to the social prescriber who held a weekly drop-in session at the practice.

The GP National Patient Survey data from 2023 showed 69.5% of patients said the last healthcare professional they saw was good at listening to them (expected 85%). Data from the published 2024 survey reviewed by the provider showed 79% of patients said the last healthcare professional was good at listening to them (national average 87%).

Leaders told us care and treatment was delivered following evidence-based guidelines and staff confirmed any updates were discussed at their regular clinical meetings.

The practice had completed a number of clinical audits. This ensured the quality and safety of people’s care and treatment was effectively monitored, to improve their outcomes. However, attainment for the management of childhood immunisation and cervical cytology screening was below local and national averages. Childhood immunisation data did not meet the national WHO (world health organisation) target of 90% and they were achieving 57.9% for cervical cancer screening which is below the national target of 80%. In 2023 the provider sent a questionnaire in different languages to patients who were due their cytology screening to understand the reasons for poor uptake. The main reason identified was access. Clinics were added to nurse rotas and patients were invited to book their appointment electronically with interpreter services available. Practice data showed a 30% increase in the same period in 2024 compared to 2023. The provider had also worked with behavioural science consultants, community workers, social prescribers and their primary care network (PCN) to develop bespoke behavioural science training and resources for local practices to try to improve the uptake of cancer screening. The attainment for the uptake of childhood immunisations was below national averages. The provider was aware of this and had reviewed ways to increase uptake. For example, staff had been into the local schools to do question and answer sessions with parents to try to answer any concerns they had and had introduced a local drop-in immunisation clinic. We observed from the clinical searches we carried out that the service delivered evidence-based care though some recording of risk advice and monitoring processes required review. For example, the process for following up of patients with asthma when they had been prescribed emergency steroids. We saw evidence action was taken immediately following the clinical searches to improve these processes.

Staff told us they worked well as a team and were able to request support from the GPs and leadership team. There was a duty doctor on call daily who supported the care navigators on the telephone.

The practice was part of a primary care network (PCN) of practices who shared staff and services for the benefit of patients. For example, the provider had worked with the local drug and alcohol service and had set up a fortnightly outreach clinic at the practice for patients who had not accessed services centrally. Clinicians worked with other health and care professionals, for example, district nurses and health visitors to carry out care planning reviews to deliver a coordinated package of care for people with the most complex needs. The provider told us due to their patient demographics they had extensive experience of working with their Roma community and were passionate about advocating for them to increase understanding of their needs. To increase local health systems awareness and promote cultural understanding and sensitivity they had delivered training to a number of local health services and had worked in collaboration with the South Yorkshire Integrated Care Board (ICB) to develop a special interest group with members from across health, housing, education and Roma advocates and community leaders to share expertise, training and best practice. The provider had worked in collaboration with a local school to expose students to the possibility of careers in healthcare. This entailed a tour of the practice, speaking to staff members and practical sessions with some equipment like blood pressure taking. The provider had received positive feedback from the school regarding this. The provider had worked with a registered charity to offer a horticultural therapy project to improve mental health through gardening for patients with severe enduring mental health needs and had supported by providing allotment areas.

The provider had a General Data Protection Regulation (GDPR) policy in place and safe processes for information sharing. Referrals and review of incoming letters and hospital discharges were completed in a timely manner.

The majority of patients we received feedback from were happy with the treatment and care that they received.

Staff told us that patients had access to appropriate health assessments and checks. Patients with long term conditions were offered an annual review. Staff told us they had been into local schools to offer question and answer sessions during the measles outbreak to support uptake of childhood immunisation and had also held a session for parents around when to keep a child off school with illness to improve school attendance.

Staff were consistent and proactive in helping patients to live healthier lives. For example, the practice had been supporting a primary mental health care project for a number of years. Leaders told us the practice served a population twice the city average and 3 times the national average for severe enduring mental illness. The project provided a holistic model of care to patients over 16 years suffering with enduring mental health problems. It aimed to promote psychological, social and physical wellbeing and the practice employed and managed the 3 mental health project staff directly. Support was offered to patients through one-to-one sessions as well as through group activities such as the knit and natter group and the healthy walks scheme.

People reported they were mostly happy with their care and treatment, however, they told us that they struggled to access the practice by telephone or to an acute appointment. Several working aged people, people with children and some patients whose circumstances may make them vulnerable told us they found the appointment system of telephoning at 8.30am difficult to use and this was the only option available to them to make an appointment.

Staff carrying out long-term condition reviews told us they had received appropriate training for the role. Staff reported they used electronic templates for recording long term condition consultations which were in line with best practice recommendations.

The practice had completed several clinical audits and had taken action to improve outcomes for patients. There was a structured system in place for inviting patients in for their long-term condition annual reviews and there were designated administration staff who had oversight of this.

Our clinical searches mostly showed appropriate monitoring of patients with long term conditions and those on high-risk medicines, although some areas required review. Areas identified that required review, for example, monitoring of patients on Gabapentoid medications, risk advice to patients on SGLT-2 medicines and follow up of patients with asthma treated with emergency steroids were responded to in a timely manner and actions to improve had been completed by the time of the on-site inspection.

We did not receive any concerns from patients relating to consent to care and treatment.

Staff had a good understanding of consent including mental capacity act and had received appropriate safeguarding training. We observed written consent forms were used for some procedures.

Patients were offered a chaperone when carrying out examinations, we saw posters displayed in the practice informing patients of this. Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check.